From the Initial Enrollment Period to the Annual Enrollment Period, you are advised on when you should sign up for Medicare. However, it is not always clear when those Medicare benefits actually begin. If you are not careful, there can be gaps in coverage that leave you without access to the care you need.
Even if you sign up during your Initial Enrollment Period, the date your benefits kick in may vary.
The Initial Enrollment Period (IEP) starts three months before the month you turn 65 and ends three months after you the month you turn 65 . This gives you seven months to sign up for Medicare without facing late penalties.
When you sign up in the first three months of your IEP, Medicare coverage starts the month you turn 65. When you sign up in your birth month or in the following three months of your IEP, your benefits start the next month.
Even when you follow the rules and enroll during the IEP, you could face a significant gap in coverage. Thankfully, the Centers for Medicare and Medicaid Services has proposed a policy change to address this. This is based on the BENES Act that passed in late 2020. Starting on January 1, 2023, anyone signing up for Medicare in the last three months of their IEP will receive benefits the month after they enroll.
How long do I have to wait for benefits when I sign up during the General Enrollment Period?
When you miss the IEP (based on age or disability), you have to wait until the General Enrollment Period (January 1 – March 31) to apply for Medicare. This could leave you waiting several months just for the opportunity to sign up. When you finally do enroll, benefits start the first day of the next month.
Is there a delay in Medicare coverage when I have kidney disease or a disability?
Not everyone on Medicare is 65 or older. According to CMS, as many as 10.8% of Americans qualify for Medicare in 2024 based on a disability or qualifying medical condition.
To qualify for Medicare, an individual must first receive Social Security Disability Insurance (SSDI) or Railroad Retirement Board (RRB) disability benefits. The application process for these benefits can take up to seven monthsand there is an additional five-month waiting period from the time an application is approved until the time benefits are paid out. For most disabilities, Medicare coverage does not start until the 25th month of benefits.
When do Medicare benefits start if you have ALS?
Most people on Social Security Disability Insurance get Medicare coverage on their 25th month of SSDI benefits. However, because amyotrophic lateral sclerosis (ALS) is a rapidly progressive disease, Medicare benefits start the first month you receive SSDI benefits.
Also, people with ALS do not have a five-month waiting period for SSDI like other people with disabilities do.
When do Medicare benefits start if you have ESRD?
People with end-stage renal disease (ESRD) need dialysis or a kidney transplant. Their Medicare benefits start on their fourth month of dialysis if they receive the treatment at a clinic, hospital, or medical office but could start on their first month of dialysis if they receive their treatments at home.
Alternatively, benefits can start right away when someone is admitted to a hospital for a kidney transplant and that transplant takes place within two months. If it takes longer than two months to get the transplant, Medicare coverage starts two months before the transplant is actually completed.
What makes ESRD coverage different from other types of Medicare coverage is that ESRD coverage has an end date. Benefits stop 12 months after dialysis treatments are discontinued or 36 months after a successful kidney transplant.
The problem is that people need to take life-long immunosuppressive drugs to prevent their body from rejecting a transplant. Losing Medicare coverage could affect their ability to afford these necessary medications. This is why Medicare began to offer a new Part B benefit referred to as Part B-ID benefit – the ID referring to immunosuppressive drugs.
Starting on Jan. 1, 2023, people with kidney transplants who do not have other health coverage can sign up to cover those drug treatments. Part B-ID does not include other Part B benefits and as a result, the monthly premiums would be lower. Similar to regular Part B, benefits for Part B-ID begin the month after you sign up.
Are there special enrollment periods that could help me get coverage sooner?
Not everyone signs up for Medicare during the IEP based on age. If you are still working and have a health plan through your employer (or your spouse does), you can wait to sign up for Medicare. When you (or your spouse) leave your job or the health plan – whichever happens first – you have eight months to sign up for Medicare. Your benefits start the month after you sign up.
That said, it is important to understand that small employers – those with fewer than 20 employees – may require you to sign up for Medicare when you turn 65 in order to keep your health plan. You should reach out to your employer to find out how their plan works with Medicare.
While you have an opportunity to change Medicare plans every year during the Annual Enrollment Period (October 15 – December 7), there are not many other opportunities to sign up for Medicare that first time.
If the COVID pandemic taught us anything, it’s that not everything is within our control. CMS understands that. Starting on Jan. 1, 2023, they enacted a new set of Special Enrollment Periods to give you more options to sign up for Medicare that first time.
It takes a number of situations into consideration that could cause you to miss your IEP. They include emergencies and natural disasters (including pandemics), loss of Medicaid coverage, misleading information from your employer or health plan, and release from prison. It also allows Medicare to look into circumstances on a case-by-case basis.
Tanya Feke, M.D. is a licensed, board-certified family physician living in New Hampshire. As a practicing primary care physician in Connecticut and an urgent care physician in New Hampshire, she saw first-hand how Medicare impacted her patients. In recent years, her career path has shifted to consultant work with a focus on utilization review and medical necessity compliance.
Dr. Feke is an expert in the field, having Medicare experience on the frontlines with both patients and hospital systems. To educate the public about ongoing issues with the program, she authored Medicare Essentials: A Physician Insider Reveals the Fine Print. Her analysis of Medicare issues is frequently referenced by the media and she is a contributor to multiple online publications. As founder of Diagnosis Life, LLC, she also posts regular content about health and wellness to her site at diagnosislife.com.
Footnotes
Tags: amyotrophic lateral sclerosis, End Stage Renal Disease, enrollment
